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141
Table 8.2 Presents the main results of the 18days-period of CPAP usage. We can observe a good
control of residual AHI (4.3event/h). OSA severity is dened as mild for apnea-hypopnea index
(AHI)≥5 and<15, moderate for AHI≥15 and≤30, and severe for AHI>30/h [1, 2]. Source:
Author’s collection
18days-period of CPAP
usage
Usage days/total days (percentile of more than 4hours of usage
per night)
18/18 (88%)
Mask Oronasal
Pressure—cmH
2
O 5.6–13.0
Average usage (total days)—Hours 6:43
Median usage (days used)—hours 7:32
Expiratory relief Off
95th percentile leaks—L/min 25.8
Median leaks—L/min 1.8
Events per hour (residual AHI) 4.3
Central apnea index 0.4
Obstructive apnea index 1.3
Obstructive hypopnea index 2.1
Unknown apnea index 0.0
After initiating pressure therapy, the patient reported that he began walking lon-
ger distances and with less fatigue. The patient reported an improvement in his
mood and vitality, restorative sleep, and improvement in daytime fatigue. He also
indicated that he could perform daily activities that he previously had trouble with.
Her family also mentioned that the patient had improved physically.
Take Away Message
1. Anatomical factors combined with body position during sleep can alter respira-
tory patterns throughout the night. In this case, the supine position was the causal
factor in the residual obstructive events during sleep, probably due to the action
of gravity on the base of the tongue and soft palate.
2. It is important to note that certain patients tend to sleep more in the supine posi-
tion during PSG than during home sleep, so a one-night sleep study may be
insufcient and may overestimate the severity of OSA in these individuals. As
the patient in this case remained only supine in the PSG, this may have overesti-
mated the severity of his sleep apnea.
3. Increasing CPAP pressure is not always the way to improve supine breathing (as
increased pressure can cause discomfort, central respiratory events, and increased
leakage).
4. Identifying external factors that may affect the patient’s breathing is of funda-
mental importance for the proper conduct of the airway pressure adaptation
program.
5. Evaluation of high-resolution graphical data and sleep ow curves is a low-cost
and highly benecial procedure for the proper performance of positive airway
pressure therapy.
8.2 Therapeutic Intervention
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References
1. Berry RBBR, Gamaldo CE, Harding SM, Marcus CL, Vaughn BV, Tangredi MM, for the
American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and
associated events: rules, terminology and technical specications. Darien, IL: www.aasmnet.
org; 2012.
2. Berry RB, Brooks R, Gamaldo C, Harding SM, Lloyd RM, Quan SF, et al. AASM scoring
manual updates for 2017 (version 2.4). J Clin Sleep Med. 2017;13(5):665–6. https://doi.
org/10.5664/jcsm.6576.
3. Kribbs NB, Pack AI, Kline LR, Smith PL, Schwartz AR, Schubert NM, etal. Objective mea-
surement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev
Respir Dis. 1993;147(4):887–95. https://doi.org/10.1164/ajrccm/147.4.887.
4. Issa FG, Sullivan CE. Reversal of central sleep apnea using nasal CPAP. Chest.
1986;90(2):165–71. https://doi.org/10.1378/chest.90.2.165.
8 Case Report: Positional Sleep Apnea
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Chapter 9
Case Report: Leaking Through theMouth
9.1 Patient Information
A 64-year-old male, BMI 27.3kg/m
2
, modied Mallampati scale: 4, 95% SaO
2
and
HR 65bpm, at rest. A history of tonsillectomy surgery, non-smoking, drinking-
free, and practicing daily physical activity. The patient uses pitavastatine, metfor-
min hydrochloride, latanoprost, and an herbal sleeping pill. The patient reports that
he usually goes to bed at 11PM. and wakes up at 5AM.For further information,
the patient has reported using a mandibular advancement device (MAD) for
10years.
A previous diagnostic polysomnography was performed using MAD (Fig.9.1).
Examination was carried out in a Nihon Kohden device, with simultaneous electro-
encephalogram evaluation (F3-M2, C3-M2, O1-M2, F4-M1, C4-M1, O2-M1), elec-
trooculogram, electromyogram (submental region and tibialis anterior muscle),
body position, snoring, nasal pressure transducer, effort thoracic and abdominal
breathing, arterial oxygen saturation (SaO
2
) and electrocardiogram. The total regis-
tration time was 428.5min. Stage N1 latency was 8.5min (normal <30min) while
REM latency was 115.0min (normal=70–120min). Total sleep time was 364.5min
(85.06% efciency; normal >85%) and the percentages of sleep phases in relation
to the total time of sleep were: N1: 17.7%; N2: 43.1%; N3: 22.1%; REM sleep:
17.1%. Wake-up time after starting sleep was 50 min. There were 175 micro-
arousals (duration <15s), with an index of 28.8/h (normal <10/h). 207 respiratory
pauses were recorded during sleep, divided into 79 apneas (79 obstructive, 0 mixed,
0 central), and 128 hypopneas. Basal SaO
2
was 94%, average SaO
2
was 94% and
minimum SaO
2
was 80%, with 2.7% of sleep time below 90% of SaO
2
. The apnea-
hypopnea index (AHI) was 34.1/h (normal <5/h). Heart rate ranged between 49 and
75bpm (mean 54 bpm), sinus rhythm. No periodical movement of limbs during
sleep was observed.
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
V. S. Piccin, Monitoring Positive Pressure Therapy in Sleep-Related Breathing
Disorders, https://doi.org/10.1007/978-3-031-50292-7_9
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144
Fig. 9.1 Patient hypnogram derived from polysomnographic examination by using a mandibular
advancement device, showing that respiratory events are predominant, albeit not exclusively pres-
ent in NREMS and at the supine position during sleep. Body position– R right lateral decubitus, B
supine (Back), F prone (Front), and L left lateral decubitus. (Source: author’s collection)
Then a new polysomnography examination without MAD was carried out
(Fig.9.2). The examination was recorded in the Alice 6 LDxS system. Sleep latency
was 5.5min and latency to initiate REM sleep was 80.0min. Total sleep time (TTS)
was 388.5min, with a sleep efciency of 87.7%. The sleep stage distribution was
7.7% stage N1, 56.5% stage N2, 19.9% stage N3, and 15.8% REM sleep. Wake-up
time after falling asleep was 48.8min. There were 150 awakenings, with an index
of 22.2 (n°/h). The index for the periodical movement of the lower limbs was 0.0
(n°/h), with 0.0 (n°/h) associated with the awakenings. The total number of respira-
tory events was 172, of which 79 were obstructive apneas, 9 central apneas, 0 mixed
apneas, 84 obstructive hypopneas, 0 central hypopneas, and 0 “RERAs”. The respi-
ratory disturbance index (RDI) was 26.6 (n°/h) and the apnea/hypopnea index (AHI)
26.6 (no./h). The obstructive apnea/hypopnea index (AHI) was 25.20 (n°/h) and the
central apnea/hypopnea (AHC) was 1.40 (n°/h). Basal oxyhemoglobin saturation
was 95%, average 92%, and minimum SaO
2
was 76%. The desaturation index was
45.9 (n°/h) during REM sleep and 23.5 (n°/h) during NREM sleep. At 7.7% of the
total registration time, SpO
2
stayed below 90%.
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145
Fig. 9.2 Patient hypnogram derived from a polysomnography exam without a mandibular
advancement device. Contrary to Fig.9.1 respiratory events are not predominant in NREM and at
the supine position during sleep. FC, BPM heart rate in beat per minute; AC central apnea; AO
obstructive apnea; AM mixed apnea; HIPO hypopnea; Estagio: sleep stage; Pos positioning; MIC
microfone; Mov Per leg movement; despertar arousal. Body position—S supine, E left lateral
decubitus. (Source: author’s collection)
After the second polysomnography (performed without mandibular advance-
ment device), and because of complaints of sleep interruptions and diurnal drowsi-
ness, the patient was referred for PAP therapy.
9.1 Patient Information
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9.2 Therapeutic Intervention
The patient started pressure therapy using automatic CPAP (5.4–8.0 cmH
2
O) with a
medium size AirFit P10 ResMed nose mask. Despite satisfactory treatment results,
the patient complained of excessive leakage of air from the mouth (Table9.1).
It was suggested that the adhesive tape method (Fig.9.3) be used temporarily to
stimulate the orbicularis oris muscle to hold a lip seal while sleeping. The patient
was also referred for myofunctional therapy, considering that the change in the mus-
cle tone of the upper airway muscles may be the causal factor for mouth opening
when using CPAP [1].
Table 9.1 Presents the main results of the various approaches to the use of CPAP (nasal mask,
nasal mask with oral tape, and oronasal mask). CPAP pressure has been adjusted to offer treatment
benets and patient comfort. We can observe the residual AHI control in all approaches. OSA
severity is dened as mild for apnea-hypopnea index (AHI)≥5 and<15, moderate for AHI≥15
and≤30, and severe for AHI>30/h. [2, 3] Source: Author’s collection
27days-period of
CPAP use
32days-period of
CPAP use
11days-period of
CPAP use
Usage days/total days (percentile of
more than 4h of usage per night)
26/27 (88%) 32/32 (96%) 11/11 (63%)
Mask Nasal Nasal with
mouth tape
Oronasal
Pressure– cmH
2
O 5.4–8.0 5.4–7.4 5.4–8.2
Median pressure– cmH
2
O 7.1 6.7 7.6
Pressure 95th percentile– cmH
2
O 7.9 7.3 8.2
Average usage (total days)– Hours 6:08 6:18 5:24
Median usage (days used)- hours 6:40 6:25 5:52
Expiratory relief Off Off Off
95th percentile leaks– L/min 27.6 24.0 0.0
Median leaks– L/min 9.0 6.0 0.0
Events per hour (residual AHI) 0.9 1.1 3.3
Central apnea index 0.4 0.5 0.6
Obstructive apnea index 0.0 0.0 1.1
Obstructive hypopnea index 0.3 0.5 0.8
Unknown apnea index 0.0 0.0 0.0
Fig. 9.3 A method of closing the mouth with a skin-friendly tape to encourage lip tightness and
control mouth leakage during the use of CPAP, used by the patient. (Source: own work)
9 Case Report: Leaking Through theMouth
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147
a
b
c
Fig. 9.4 Provide examples of the respiratory ow curve using a nasal mask without the mouth
tape (a), a nasal mask with mouth tape (b), and an oronasal mask (c). The 95th percentile leak was
27.6, 24.0, and 0.0 at A, B, and C respectively. The more leak control, the less “spiculated” pattern
presents the expiratory ow curve (black arrow) and the wider is the inspiratory ow curve (white
arrow). Source: Author’s collection
The patient obtained improved oral air leakage control when using the CPAP
with the mouth tape (Table9.1). Unfortunately, he started but failed to follow-up on
functional myotherapy.
Despite not presenting complaints regarding the use of adhesive tape in conjunc-
tion with pressure therapy, the patient was invited to try the oronasal interface
(AirFit F30i ResMed medium size), where he presented excellent control of air
leakage. However, the patient reported discomfort with the oronasal mask and pre-
ferred to keep the adhesive tape together with the nasal mask when using
CPAP.Table9.1 shows the CPAP results with the different approaches used.
Interestingly, it was possible to observe in the respiratory ow curve during sleep
how, with the air leakage control through the different methods used (nasal mask
without the mouth tape, nasal mask with mouth tape, and an oronasal mask), the
expiratory ow curve became less “spiculated” and the inspiratory ow curve began
to show an increase in its amplitude (Fig.9.4).
Despite the studies showing the benet of using the chinstrap in controlling oral
leakage, [4] the patient refused to use this accessory concomitantly with the nasal
mask. In the end, the patient chose to keep the adhesive tape together with the nasal
mask when using CPAP.
Take Away Message
1. Unintentional air leakage from the mouth may contribute to patient discomfort
when using CPAP.
2. Some methods can help control air leakage from the mouth while using CPAP,
such as the use of skin-safe tape on the mouth, chinstrap, myofunctional therapy,
and the oronasal mask.
9.2 Therapeutic Intervention
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148
3. Oral leakage control methods depend not only on their efcacy, but also on the
availability and comfort of the patient to use the method.
4. Assessing the breathing ow curve during sleep is an excellent practice for
checking the results of oral leak control methods in a more objective manner.
References
1. Lebret M, Martinot JB, Arnol N, Zerillo D, Tamisier R, Pepin JL, etal. Factors contributing to
unintentional leak during CPAP treatment: a systematic review. Chest. 2017;151(3):707–19.
https://doi.org/10.1016/j.chest.2016.11.049.
2. Berry RBBR, Gamaldo CE, Harding SM, Marcus CL, Vaughn BV, Tangredi MM, for the
American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and
associated events: rules, terminology and technical specications. Darien, IL: www.aasmnet.
org; 2012.
3. Berry RB, Brooks R, Gamaldo C, Harding SM, Lloyd RM, Quan SF, et al. AASM scoring
manual updates for 2017 (version 2.4). J Clin Sleep Med. 2017;13(5):665–6. https://doi.
org/10.5664/jcsm.6576.
4. Bachour A, Hurmerinta K, Maasilta P.Mouth closing device (chinstrap) reduces mouth leak
during nasal CPAP.Sleep Med. 2004;5(3):261–7. https://doi.org/10.1016/j.sleep.2003.11.004.
9 Case Report: Leaking Through theMouth
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149© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
V. S. Piccin, Monitoring Positive Pressure Therapy in Sleep-Related Breathing
Disorders, https://doi.org/10.1007/978-3-031-50292-7_10
Chapter 10
Case Report: Obstructive Sleep Apnea
andObesity Hypoventilation Syndrome
10.1 Patient Information
A 26-year-old woman, BMI 58.1kg/m
2
, complained of morning fatigue, snoring,
and reported worsening of her breathing over the past 2months. She explains that
dyspnea sometimes occurs during sleep and is associated with nightmares. The
patient also had a medical record of epilepsy and obsessive-compulsive behavior
disorder. Aripiprazole, sertraline, and alprazolam are utilized daily.
She underwent video-EEG monitoring (traditional 10–20 electrode placement
system). Background activity during wakefulness revealed a posterior rhythm of
9–10Hz. During the assessment, no clinical and/or electrographic seizures occurred.
The evaluation found a slight disorganization of basal activity in the anterior and
middle temporal region to the right. Epileptiform paroxysms of sharp waves, of
moderate to high amplitude, were also noted amidst irregular slow waves of projec-
tion in the right temporal region, with maximum electronegativity oscillating mainly
between the zygomatic (Zig2) and anterior temporal (FT8) electrodes, activated by
drowsiness and sleep.
The patient was also referred for diagnostic polysomnography that showed a
marked increase in the apnea/hypopnea index (92.6/h) with the occurrence of cen-
tral apneas (8.0), mixed apneas (4.0), obstructive apneas (24.0), and a predominance
of hypopneas (406 hypopnea events, and a hypopnea index of 85.0/h). Basal oxygen
saturation was 92%. Average oxygen saturation overnight was 87%, minimum SaO
2
was 60%, and 69.9% of the total sleep time remained with saturation below 90%,
The patient presented an increased number of awakenings (91.9/h), latency for the
N2 sleep stage was about 22.5min and REM sleep latency was about 97.5min. The
sleep efciency was 82.6%. Sleep architecture presented N1: 0.7%; N2: 79.2%; N3:
6.3%; REM: 13.6%. The examination was carried out in ambient air to better evalu-
ate respiratory events.
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The sleep test was compatible with severe sleep apnea. Likewise, the patient’s
sleep test and clinical condition indicated the possibility of obesity hypoventilation
concomitant with sleep-disordered breathing. Following evaluation of the polysom-
nography test results, the patient was referred to positive airway pressure (PAP)
therapy.
10.2 Therapeutic Intervention
The patient underwent a PAP test using a CPAP device coupled to an oximetry
module, several nights, with a xed CPAP pressure beginning at 8.0 cmH
2
O.She
was wearing a pillow mask AirFit P10 ResMed, small size. The patient underwent
7-day CPAP monitoring with OSA resolution and excellent compliance results
(Table 10.1). It is very important to note that all therapy adjustments were done
remotely. Currently, the remote monitoring system, for patients who use sleep pres-
sure therapy, is an essential tool for rapid verication of PAP and therapeutic adjust-
ment. This system even allows the visualization of oximetry data throughout the
night when the oximetry module is coupled to the positive pressure device [1, 2]. In
addition to data monitoring through the telemonitoring system, the patient was
asked daily, by telephone contact, about her comfort with the pressure therapy the
night before, and the pressure parameters were only adjusted based on the patient’s
comfort report and with patient consent.
At 14.0 cmH
2
O, the resolution of apneic events (which had already occurred
with a therapeutic pressure of 8.6 cmH
2
O) and improved hypoventilation could be
Table 10.1 Nights when PAP treatment was tested, with different CPAP pressure parameters
during sleep
Night 1 Night 2 Night 3 Night 4 Night 5 Night 6 Night 7
CPAP pressure 8.0
cmH
2
O
8.6
cmH
2
O
9.6
cmH
2
O
11.0
cmH
2
O
12.0
cmH
2
O
13.0
cmH
2
O
14.0
cmH
2
O
SaO
2
minimum 85 87 85 68 72 81 84
SaO
2
median 92 93 92 93 93 93 93
SaO
2
maximum 98 98 96 98 100 98 97
Time SaO
2
<90%
(hours)
00:17 00:20 00:40 00:24 00:15 00:32 00:04
AHI 6.5 0.0 0.1 0.9 0.2 0.0 0.2
CPAP usage
(hours)
05:59 07:26 07:18 08:07 06:42 06:36 06:58
Leak (l/min at 95
percentile)
9.6 1.2 2.4 2.4 3.6 3.6 4.8
ODI 9 4 6 4 5 2 2
PAP positive airway pressure, CPAP continuous positive airway pressure, SaO
2
oxygen saturation
of arterial blood, AHI apnea-hypopnea index, ODI oxygen desaturation index
10 Case Report: Obstructive Sleep Apnea andObesity Hypoventilation Syndrome
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